Provider Demographics
NPI:1518667104
Name:VANCOPPENOLLE, KANDISS
Entity type:Individual
Prefix:
First Name:KANDISS
Middle Name:
Last Name:VANCOPPENOLLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 S WINTER ST APT G11
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-8785
Mailing Address - Country:US
Mailing Address - Phone:517-422-0207
Mailing Address - Fax:
Practice Address - Street 1:216 N MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-2786
Practice Address - Country:US
Practice Address - Phone:517-442-0207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-03
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011113811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical